VA system ill-equipped to treat mental anguish of war, 2/5/07

FORRESTON, Ill—A year ago on Thanksgiving morning, in the corrugated metal pole barn that housed his family's electrical business, Timothy Bowman put a handgun to his head and pulled the trigger. The bullet only grazed his forehead. So he put the gun in his mouth and pulled the trigger again.

He had been home from the Iraq war for only eight months. Once a fun-loving, life-of-the-party type, Bowman had slipped into an abyss, tormented by things he'd been ordered to do in war.

"I'm OK. I can deal with it," he would say whenever his father, Mike, urged him to get counseling.

The Department of Veterans Affairs is facing a wave of returning veterans like Bowman who are struggling with memories of a war where it's hard to distinguish innocent civilians from enemy fighters and where the threat of suicide attacks and roadside bombs haunts the most routine mission. Since 2001, about 1.4 million Americans have served in Iraq, Afghanistan or other locations in the global war on terror.

The VA counts post-traumatic stress disorder, or PTSD, as the most prevalent mental health malady—and one of the top illnesses overall—to emerge from the wars in Iraq and Afghanistan.

VA Secretary James Nicholson and other top administration officials have said that the agency is well-equipped to handle any onslaught of mental health issues and that it plans to continue beefing up mental health care and access under the administration budget proposal released last week.

But an investigation by McClatchy Newspapers has found that even by its own measures, the VA isn't prepared to give returning veterans the care that could best help them overcome destructive, and sometimes fatal, mental health ailments.

McClatchy relied on the VA's own reports, as well as an analysis of VA data released under the federal Freedom of Information Act. McClatchy analyzed 200 million records, including every medical appointment in the system in 2005, accessed VA documents and spoke with mental health experts, veterans and their families from around the country.

Among the findings:

Despite a decade-long effort to treat veterans at all VA locations, nearly 100 local VA clinics provided virtually no mental health care in 2005. Beyond that, the intensity of treatment has worsened. Today, the average veteran with psychiatric troubles gets about one-third fewer visits with specialists than he would have received a decade ago.

Mental health care is wildly inconsistent from state to state. In some places, veterans get individual psychotherapy sessions. In others, they meet mostly for group therapy. Some veterans are cared for by psychiatrists; others see social workers.

And in some of its medical centers, the VA spends as much as $2,000 for outpatient psychiatric treatment for each veteran; in others, the outlay is only $500.

The lack of adequate psychiatric care strikes hard in the western and rural states that have supplied a disproportionate share of the soldiers in the wars in Iraq and Afghanistan—often because of their large contingents of National Guard and Army Reserves. More often than not, mental health services in those states rank near the bottom in a key VA measure of access. Montana, for example, ranks fourth in sending troops to war, but last in the percentage of VA visits provided in 2005 for mental health care.

Moreover, the return of so many veterans from Iraq and Afghanistan is squeezing the VA's ability to treat yesterday's soldiers from Vietnam, Korea and World War II. And the competition for attention has intensified as the vivid sights of urban warfare in Iraq trigger new PTSD symptoms in older veterans.

"We can't do both jobs at once within current resources," a committee of VA experts wrote in a 2006 report, saying it was concerned about the absence of specialized PTSD care in many areas and the decline in the number of PTSD visits veterans receive.

"There are VA facilities that were fine in peacetime but are now finding themselves overwhelmed," said Steve Robinson, government relations director of the Washington-based advocacy group Veterans for America. "So they're pitting the needs of the veterans of previous wars against the needs of Iraq veterans."

While the debate in the VA about the level of its psychiatric care is often frank, the public assurances of top officials are oddly optimistic.

"Mental health is a very high priority of ours," VA Secretary Nicholson said last March. "The VA possesses—this will sound boastful, but ... as we used to say back home, it ain't bragging if it's true—but we have the best expertise in post-traumatic stress disorder in the world. ... So we are ramped upward, and we have a terrific cadre of experts in that area, and we are adequately funded to deal with it."

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"We feel very well poised to meet the needs," said Antonette Zeiss, a VA health official who's helping to oversee the mental health system, in a November interview with McClatchy Newspapers.

McClatchy's investigation found otherwise, and it found that the government's failings are felt acutely by families such as the Bowmans, whose son Tim was a member of the Illinois Army National Guard.

A young warrior who spent months patrolling the treacherous highway that runs between the Baghdad airport and the city's fortified Green Zone, Tim received several medals and is set to be posthumously awarded the Purple Heart.

"Tim always referred to the National Guard soldiers as the Army's disposable soldiers," his father, Mike Bowman, said. "Six months of training to kill, 12 months of the nastiest duty in Iraq and then two weeks that the Army gave them to be re-educated back to civilian life.

"It's not humanly possible to readjust to civilian life with that type of treatment," he said.

Soldiers coming home today walk into a VA health system that's nothing like it was when veterans returned from World War II, Korea, Vietnam or even the first Gulf War.

The change began more than a decade ago, when the agency decided to move away from focusing on high-cost inpatient hospital care and toward outpatient clinics that could tend to veterans' primary care needs.

In addition, the VA scrapped its organizational structure and created about 20 networks, more than 150 hospitals and—as of today—more than 800 outpatient clinics. The new system would provide "easier access to care and greater consistency in the quality of care," the VA said in a March 1995 report.

At the same time, Congress passed legislation to make sure that the VA didn't skimp on mental health care, with a key committee saying it was concerned that mental health and other specialized treatment "may be particularly vulnerable and disproportionately subject to budget cutting." The reason? The "newly decentralized organization, under budget pressures and focused heavily on instituting new primary care programs" might cut the very programs on which "the Department's most vulnerable beneficiaries depend," a congressional report said.

Congress ordered the VA to maintain the "capacity" of its mental health care programs.

Over the next several years, however, VA management and a committee of its mental health experts bickered over what "capacity" meant.

The expert committee said that "capacity" meant the number of people served in special mental health programs and the amount of money spent, adjusted for inflation. The VA administration didn't adjust for inflation.

Because specialized mental health spending inched up after 1996, the VA could report to Congress every year that it was maintaining the capacity of its mental health services.

Its committee of experts, however, said that specialized mental health services were declining and that the VA's use of unadjusted dollars in an era of high inflation in medical costs rendered its annual reports "meaningless."

At the same time, the VA began treating many more people for mental health ailments, so the amount spent has plummeted from $3,560 per veteran in 1995 to $2,581 per veteran in 2004—even before correcting for inflation. (Overall, mental health spending during that period went from $2.01 billion to $2.19 billion.)

In the past two years, the VA has committed more money to mental health care and brought services to previously underserved areas. But it's also changed its accounting system, so it's difficult to compare spending after 2005 with that of prior years.

What does this all mean for veterans?

It means that veterans receive fewer visits to mental health professionals, on average, than they did before. Between 1995 and the first half of fiscal 2006, for example, general psychiatry visits for those in the mental health system dropped from an average of 11.7 a year to 8.1 a year per veteran, according to VA data.

VA experts said the system already was straining to provide veterans with what they needed before the United States attacked Afghanistan in October 2001. "Even before the war in Afghanistan," Matthew Friedman, a top VA mental health official, told Congress in 2004, "VA PTSD treatment capacity had been overtaxed."

In 2003, a committee of VA insiders said that "it is unfortunate that the decentralization ... was accompanied by substantial erosion of mental health services."

In 2006, a separate committee of VA experts declared that the "VA cannot meet the ongoing needs of veterans of past deployments while also reaching out to new combat veterans ... and their families by employing older models of care. We have a new job and we need to do it in a new way."

Veterans and their families are often caught completely unprepared.

In the small town of Grundy Center, Iowa, Randy and Ellen Omvig keep a large plastic freezer bag. Inside is a piece of torn paper with "Mom & Dad" written at the top.

When she first saw it in December 2005, Ellen thought it was a Christmas list from her son Josh, who had just walked out the front door.

Then she read the words:

"Don't think this is because of you," it said. "You did the best you could with me. The faces and the voices just won't go away."

The note indicated Josh's imminent suicide and went on to apologize for the pain he would cause. He said he had just received a driving-while-intoxicated charge—a surprise since he rarely drank. "This kills all hope of becoming a police officer that I ever had," he wrote.

By the time Ellen realized what the note was about, she ran outside. Josh was getting in his truck. She grabbed the side mirror, yelling hysterically that he would have to run her over before driving away. He yelled back, about a friend who had been killed in Iraq.

"Your battle buddy would not want you to die," she screamed.

"Mom, you don't understand," he said. "I've been dead ever since I left Iraq."

Josh shot himself in the head a few seconds later, as a police officer—and close friend—pulled up. His case made local headlines and has since become the inspiration for legislation in Congress to better prevent veteran suicides.

Josh Omvig had been a happy kid who signed up for the Army Reserves the day after he turned 18. He spent an intense 10 months in Iraq and then suddenly was home again. In the space of six days, he went from serving in Iraq to sitting at his family's Thanksgiving dinner table.

In the 13 months that followed, it was clear that Josh had changed. His parents urged him to get help. But he was convinced that showing up at the VA would go on his record, costing him a career in the military and law enforcement.

The Omvigs believe the nation faces a cascade of mental health problems.

"There are so many Joshes coming back now," Randy Omvig said.

In many respects, the Omvigs' story is remarkably similar to that of the Bowmans', whose son Tim killed himself on Thanksgiving Day in 2005.

It's impossible to know what goes through the mind of any suicidal veteran, or whether VA care would have made a difference. But as he tries to rebuild his life without his son, Mike Bowman is convinced that even a little care would have been better than none.

Tim Bowman joined the National Guard after Sept. 11 but before the Iraq war.

He was a charming jokester, a small-town kid who played musical instruments in high school, attended some junior college and then went to work in his family's electrical business in Polo, Ill.

He left for the war on March 4, 2004, his 22nd birthday.

Over the next 12 months, his assignments varied, but among them was helping patrol Route Irish, the treacherous airport highway. He told his father about having to bag body parts.

In his communications back home, Tim became an expert at withholding the details of his reality. He did open up once, however. Home for a short leave, Tim and his father stopped for a beer after a softball game. They got into their deepest conversation about the war and even talked about an episode in which Tim, as the last line of defense, said he was forced to shoot at a car—with a family inside—that had failed to stop at a checkpoint.

"He was really quiet as he told me—not at all the normal Tim," his father said. (His commander at the time said he is unaware of any incident like Tim described. Tim's father said Tim may have been involved in a shooting and "assumed the worst in his state of mind.")

At the end of his leave, Tim didn't want to go back to Iraq, but he didn't not want to go back, either. More than anything, he couldn't stand being away from his unit.

He returned home for good in March 2005. His deployment had included some mental health screening, but he told his father that it was "a joke." Soldiers coming off months of active duty would say anything during the screenings. "All they wanted to do was get home," his father said.

That was a feeling shared by Tim's commander in Iraq, Maj. Mike Kessel of Mahomet, Ill., who recently retired after 21 years in the Army National Guard. Two months before his unit returned home to Illinois, Kessel urged his bosses to change the demobilization process by letting the soldiers go home briefly before returning for health screening.

"I knew we were going to have problems," Kessel said. But his proposal was rejected.

"We got off the bus, we had a five-minute ceremony, and, boom, we were released," he said. "We didn't come back to drill for 110 days. Suddenly, your support system is gone. We had 120 people in 70 communities spread across five states."

In a 2004 study, nearly two-thirds of soldiers and Marines who met the criteria for mental health problems felt that seeking help would harm their careers, that they would been seen as weak, that superiors might treat them differently. One VA report from 2006 said that "any effort to reach out to these veterans and their families will face enormous obstacles"; it also said that the current system "follows an attitude of `ask, but don't tell.'" While every returning soldier is asked four important PTSD-related questions, "no one seems to expect them to answer truthfully."

Tim came home and tried to dive back into his life, working his electrical job and volunteering at the fire department. He'd be pleasant one minute and flip out over mild annoyances the next.

"I don't feel right here," Tim admitted during a rare candid conversation with his sister Michelle. "I'm spending too much time in the bar," he added.

Tim took a six-week National Guard assignment to help with the Hurricane Katrina recovery. His family said he relished the structure of the unit. He even began talking about the possibility of going back to Iraq.

"What better place for a soldier to die," he told his father one night.

In November, Tim scheduled an appointment with the VA. His father wasn't sure what it was for—mental issues, or perhaps follow-up for a hand injury that Tim had suffered in Iraq.

The night before Thanksgiving, Tim had a great conversation with his father and his sister. He seemed his old, jovial self. His family now believes that by then he already knew what he was about to do.

The next day, Tim didn't show up for an extended-family Thanksgiving dinner. They called and called. Finally, Mike Bowman decided to see if Tim was at the family business. He found him on the floor, shot but still breathing.

Tim died two hours later.

At Tim's funeral, Kessel, his commanding officer, found that several other soldiers were having mental troubles, too—and having trouble getting into the VA.

"They were told, `We can't get you in for six months,'" Kessel said. "We started pulling a bunch of strings and making lots of noise, and then people started listening.

"But it was one soldier too late."

The nearest VA outpatient clinic to Tim Bowman's hometown is part of the Madison, Wis., network. Like a third of all the VA medical centers in 2005, Madison didn't have a specialized PTSD clinical team, according to VA records.

That's the case despite two decades of urging by VA experts that each medical center should have such a team. "Such specialization has long been recognized as an essential feature in treatment of military-related PTSD," a 2006 VA report said. "Treatment of PTSD requires specific familiarity with the kinds of trauma veterans encountered while in military service."

Its absence in many centers exemplifies a significant—and growing—problem in the VA: the wide disparities in mental health services.

The VA's mental health experts started pushing for specialized PTSD programs in all medical centers in the 1980s. Top VA officials agreed "in concept" that it would be a good idea. But in 2005 and 2006, despite telling Congress that it was setting aside an additional $300 million for expanding mental health services, such as PTSD programs, the VA didn't get around to spending $54 million of that, according to the Government Accountability Office.

At medical centers with no specialized PTSD teams, veterans still get PTSD treatment, but not from the specialists whom the VA considers to be most essential.

In all, only 27 percent of veterans receiving PTSD care received it in one of the VA's specialized programs, VA data show. And that varies widely: In the region that includes Wisconsin, 13 percent of veterans with PTSD got care from specialized teams. In Ohio, 45 percent did.

The amount of specialized care came up at a Senate committee last February, in which VA Secretary Nicholson assured lawmakers that PTSD funding wasn't a problem. "We're certainly getting the resources" to deal with the issue, he testified. "In every one of our 154 major medical centers, we have a certified expert on PTSD."

But that doesn't come close to meeting the goals of the VA's own committee of PTSD experts, which for years had urged a full PTSD clinical team in every VA medical center—not just an expert. By 2006, there were full PTSD clinical teams in 104 of 163 medical centers; in the past, the department's inspector general has questioned whether people are really working in some of those units.

In the same month as Nicholson's testimony, the VA's PTSD expert panel sounded a different note from the secretary's. "Just having a team or a PTSD expert does not solve the problem," the committee concluded. It added: "Specialized PTSD programs are not ready to meet the ongoing needs of veterans of past deployments while also reaching out to new combat veterans."

The uneven mental health treatment of veterans across the country can be traced to the VA's health system reorganization, which gave a lot of leeway to local managers.

"Some networks did an entirely fine job in maintaining capacity for the treatment of mental illness," Thomas Horvath, a VA health official based in Houston, told Congress in 2004. "Others did a terrible job."

"There appears to be little or no rationale for the size or distribution of these programs nationally," a 2003 VA report concluded.

For the average veteran seeking care, this means that getting the best care depends on geography and luck.

Consider what the VA considers a "crucial ingredient" for measuring the comprehensiveness and consistency of its mental health treatment. Called the "continuity of care index," it shows whether veterans are getting consistent care rather than being bounced from doctor to doctor.

That continuity is absent in many parts of the country.

According to VA data, the "continuity of care index" for PTSD patients varies widely across the country, even after adjusting for patient characteristics and different diagnoses. In fact, more than a third of VA medical centers had an index rating that was "significantly different" from the national median "in the undesired direction," a 2006 VA report said.

McClatchy reviewed two dozen mental health measures, based in part on an analysis of every inpatient and outpatient visit in the VA health system. The 200 million records were contained in two fiscal 2005 databases.

Among the findings:

Some veterans get in for visits far more than others. The average number of visits per veteran with PTSD ranged from 22 in the Hudson Valley, N.Y., medical center and clinics to a low of 3.1 in Fargo, N.D. The national average was 8.1.

Some VA medical centers spend far more on mental health care than others. In Connecticut, it was an average of $2,317 for each veteran's outpatient psychiatric care. In Saginaw, Mich., it was $468.

Some veterans get in quickly. Others wait. At the Loma Linda, Calif., VA network, only 39 percent of new mental health patients were able to get appointments within 30 days, the VA's standard. In other networks, 90 percent or more did.

Once they're in the door, some veterans get visits of 75 to 80 minutes, while others get 20- to 30-minute appointments, the shortest psychotherapy appointments listed in the system. Of all the individual sessions for veterans with PTSD, those in the Amarillo, Texas, network got the shortest possible visits 87 percent of the time, while those in Butler, Pa., were given those short visits 6 percent of the time.

The VA's mental health system is nonexistent for many veterans it's supposed to serve.

One key measure is the number of veterans with mental illnesses who get all their treatment outside the VA mental health system—that is, typically from the VA's general primary care doctors. Nationwide, 22 percent of veterans got all of their mental health care outside the mental health system.

But there was a big range: In Beckley, W.Va., 10 percent got their care that way. In Montana, 52 percent did, data from 2005 show.

Asked about the disparities, the VA's Zeiss said: "It's true there are disparities. ... Disparity is a part of health care. ... I can tell you that the data you're looking at we're looking at too, and we're using it to make decisions about how to close the gap and ensure a standard of care nationally."

The VA's top mental health services official, Dr. Ira Katz, added in a separate interview that variation in a host of mental health measures wasn't necessarily good or bad. It could reflect different strategies being tried in different states so that "our system can better learn what works and what doesn't work," he said.

Through such trial and error, variations likely would decrease over time as, for example, expensive medical centers become more efficient and underserved medical centers were given more resources, he said.

So far, that hasn't happened, McClatchy found.

For starters, the variations in many mental health measures are growing, not shrinking, according to a McClatchy analysis of key measures back to the time of the reorganization. A 2005 study by two VA mental health experts found the same, noting that "system reforms did not lead to decreases in regional variation."

In addition, the variation in mental health spending is far wider than it is in primary and hospital spending, indicating that the system is having more trouble ensuring mental health consistency.

As for the wide variation in spending per veteran on mental health care, Katz said it could be explained by the presence of special programs in various medical centers. There's a national PTSD research center at the Connecticut VA, for example, that inflates spending figures there.

When asked how many of 128 medical centers ranked by that measure had special programs that might distort spending figures, Katz said he didn't know if it was a half dozen or if it was 50.

He added that "the VA is involved in a very active process of identifying and filling gaps in care."

Among other things, the VA has begun to pump more money into local clinics to ensure that they begin to provide mental health treatment. "We have invested more personnel and more money in this in 2006, and are investing still more in 2007," Katz said. The 2008 budget released last week will continue those efforts, the VA said.

It's a quiet night in the back of a community veterans' hall in Carlsbad, N.M. Eight men who served in Vietnam four decades ago are gathering to find among themselves what they can't get from the VA.

The room has cinder-block walls, a white vinyl floor and cafeteria tables. The men have brought chicken wings and egg rolls, which they share in between tales of hair-trigger rages and failed marriages. Combined, the eight men have had 25 wives. Two of them have had six each.

They have histories of post-traumatic stress disorder, tied to their service in Vietnam.

"We're just falling through the cracks, trying to do something to help ourselves," said Don Oden, who served two years in Vietnam.

Their informal support group has no mental health expert to guide it.

Getting in to see a psychiatrist can take months, and the person who led PTSD sessions at the nearest VA clinic, in Artesia, N.M., recently left the VA. Some of the men wake up at 3 a.m. to drive five hours to the VA hospital in Albuquerque to see a psychiatrist.

"I sure as hell can't go to Albuquerque two times a week," Oden said.

The veterans in Carlsbad said they try to get into the nearby VA clinic, where a psychiatrist from Albuquerque flies in to handle individual therapy sessions. But they complain of three-month gaps between appointments, and they say they're hurried in and out.

Indeed, McClatchy's analysis found that of all the individual psychotherapy sessions for PTSD at the Artesia clinic, 99 percent are for the shortest amount of time possible. The national average for short sessions is 51 percent.

Dr. Jeff Katzman, who oversees the New Mexico VA mental health system from Albuquerque, said he's working to boost the level of care in outlying clinics such as Artesia's. He hopes some new hires will allow the psychiatrist, who flies a private plane from clinic to clinic, to land in Artesia more often. He's also looking to hire somebody to replace the social worker who left last year.

Katzman said he hadn't heard that the Vietnam veterans say they face long waiting times for psychiatrist appointments. He also said he hadn't heard another of the veterans' complaints—that the Artesia clinic wouldn't set up a group session in the evening so that those with jobs could make the 40-mile drive to the clinic. He said that having a nighttime session might pose a security risk for a counselor staffing the clinic alone.

Beyond that, he said, "I am not aware of veterans who are not able to get the mental health care that they need."

The support group started nine months ago with a half-dozen veterans meeting in a Denny's restaurant. The meetings go on for a couple of hours, and the men call on each other at all hours. With no psychiatrist in town, "the only emergency services we have are each other," said Dave Ridenour, 59.

John Wixom, a burly 58-year-old with a full gray beard and long brown hair, has been in Carlsbad his whole life, except for his year of service during the Vietnam War.

He works at a potash mine east of town, maintaining its vehicles and equipment. All along, he's had trouble dealing with other people, with crowds, with Fourth of July fireworks. He flies off the handle with little provocation. "I get so mad I want to choke somebody, and I'm afraid I will choke somebody," he said.

At work, he said, colleagues drop heavy tools or whack a big metal drum "just to see me jump."

"Everybody at work knows what a Wix fit is," Wixom said.

After 35 years of suppressing his rage and drinking away his memories of Vietnam, Wixom said that his emotions are erupting more regularly. He has night sweats two to four times a week and nightmares regularly—apparently provoked by the latest war news from Iraq.